Healthcare Provider Details

I. General information

NPI: 1821553991
Provider Name (Legal Business Name): MARIA VILLEDA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/04/2019
Last Update Date: 02/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 E PALMETTO ST
WAUCHULA FL
33873-2732
US

IV. Provider business mailing address

47 5TH ST NW
WINTER HAVEN FL
33881-4672
US

V. Phone/Fax

Practice location:
  • Phone: 863-773-2111
  • Fax: 863-292-4293
Mailing address:
  • Phone: 863-291-5110
  • Fax: 863-268-7899

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH23423
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: